0
Correspondence |

ResponseResponse FREE TO VIEW

Frank C. Detterbeck, MD, FCCP
Author and Funding Information

From the Department of Surgery, Yale University.

Correspondence to: Frank C. Detterbeck, MD, FCCP, Yale University, RR 205, Department of Surgery, 330 Cedar St, Thoracic Surgery, New Haven, CT 06520; email: frank.detterbeck@yale.edu


Financial/nonfinancial disclosures: Dr Detterbeck is a member of the International Association for the Study of Lung Cancer International Staging Committee and a speaker in an educational program regarding lung cancer stage classification; both activities are funded by Lilly Oncology (Lilly USA, LLC). He has participated on a scientific advisory panel for Oncimmune (USA) LLC; an external grant administration board for Pfizer, Inc; a multicenter study of a device for Medela; and formerly a multicenter study of a device for Deep Breeze. Compensation for these activities is paid directly to Yale University. Dr Detterbeck served on the executive committee of the Diagnosis and Management of Lung Cancer, 3rd Ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(4):1420-1421. doi:10.1378/chest.13-1350
Text Size: A A A
Published online
To the Editor:

We agree with the fundamental message in the letter by Dr Young and Ms Hopkins in response to the American College of Chest Physicians lung cancer guidelines chapter on screening in CHEST.1 Their message is that screening only people at higher risk will provide more “bang for the buck,” that is, result in detection of more lung cancers per person screened. The open questions are (1) what does this mean in terms of reducing the number of deaths from lung cancer in the screened population, and (2) how should the greater detection per person screened be balanced with the fact that this results in a smaller number of people considered eligible for screening?

The table provided by the authors is interesting. A slightly different calculation of the number of cancers detected over the course of each screening study demonstrated greater differences (see Table 5 in Bach et al.2). These differences were not explained by a comparison of the stringency of the entry criteria for the studies. We should remember that the entry criteria may not reflect the overall average risk of those patients actually enrolled.

Several different risk prediction models have been developed, and some have been validated in independent datasets. However, a comparison of the risk prediction of the different models reveals some generally similar trends, but also significant differences between them when applied to individual actual people (Lynn Tanoue, MD, and Frank Detterbeck, MD, unpublished data, 2013). This underscores the complexity and the difficulty in relying on only one method.

CT image screening inherently involves a complex interplay of many factors: risk of developing lung cancer, quality of screening, judicious judgment in evaluation and management of screening findings, competing risks and compliance. Accounting for this complexity is particularly important in evaluating the effect of screening as we try to define how it will work outside the context of a controlled study. As the risk of lung cancer increases, so do the risks of competing causes of death and potential complication of screening and treatment. The elevation in risk associated with the presence of COPD is an intriguing example. Although COPD increases the risk of lung cancer, it also hinders the interpretation of CT scans, increases the risks associated with surgical treatment, and overall shortens life expectancy—all features that detract from the benefits of CT image screening. We look forward to carefully constructed modeling studies that help shed light on these matters.

References

Detterbeck FC, Mazzone PJ, Naidich DP, Bach BP. Screening for lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):e78S-e92S.
 
Bach PB, Mirkin JN, Oliver TK, et al. Benefits and harms of CT screening for lung cancer: a systematic review. JAMA. 2012;307(22):2418-2429. [CrossRef] [PubMed]
 

Figures

Tables

References

Detterbeck FC, Mazzone PJ, Naidich DP, Bach BP. Screening for lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):e78S-e92S.
 
Bach PB, Mirkin JN, Oliver TK, et al. Benefits and harms of CT screening for lung cancer: a systematic review. JAMA. 2012;307(22):2418-2429. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543